10-9
The first sample monthly report, shown below, is a short, problem-related form. It
is designed to help health workers, the community, and the health program to work
together more effectively. The second sample monthly report, on the next 2 pages,
is a longer form intended to gather more information.
Which do you prefer? We would appreciate your ideas. Please send us examples
of helpful forms used by your program. Write to Hesperian Health Guides,
1919 Addison Street #304, Berkeley, CA 94704, U.S.A. [email protected]
MONTHLY REPORT 1
Month:Â__________________
Village:_____________________________ Health worker:_______________________
How many sick people did you see this month? Men__ Women____Children___
What health problems did you see most often this month?_____________________
_ _______________________________________________________________________
What was the most serious problem you saw this month?_ ____________________
What were the causes?____________________________________________________
_ _______________________________________________________________________
_ _______________________________________________________________________
What are you doing to help prevent these problems from happening again?
___________________________________________________
Include activities of
health workers, health
committee, parents’
groups, and school
children.
___________________________________________________
___________________________________________________
___________________________________________________
What was done in the following areas?
Latrines ________________________________________________________________
Safe water supply_________________________________________________________
Village cleanliness_________________________________________________________
Vaccination_______________________________________________________________
Nutrition_________________________________________________________________
Other____________________________________________________________________
Did someone from the program visit this month?______________________________
What did you do together?_________________________________________________
_________________________________________________________________________
How is your supply of medicines?___________________________________________
What help or information do you and the health committee need in order to
do a better job?___________________________________________________
_________________________________________________________________